Village Apothecary Home Visits 2024

Village Apothecary Home Visits 2024

We'll provide COVID and flu vaccines for home-bound and bed-bound patients and their caregivers for the 2024 vaccine season. Patients living up to 60 minutes away from Woodstock should submit a form. We will review each request and contact caregivers shortly thereafter.
Name*

First NameLast Name
Are you the patient or caregiver?*

PatientCaregiver
Date of Birth*

MonthDayYear
Date
Last 4 Digits of Social Security Number*
Write 0000 if no SSN does not exist. We need this to properly assess insurance coverage and to file claims.
Best, Most Direct Phone Number of Caregiver*
Please enter a valid phone number.
Email for Communication*

Confirmation Emailexample@example.com
Physical Address*

Street Address

Street Address Line 2

City

Zip Code
Brief Reason/Diagnosis for Home-Bound or Bed-Bound Status*
If caregiver, write N/A.
Ideal Day of Week and Approximate Time for Visit*
i.e. Friday before 12. Any weekday after 3. We will attempt to accommodate requests!
By submitting this form you certify that the patient(s) in question have the appropriate medical conditions to warrant a home-bound status. You also certify that any person who will be vaccinated as a caregiver are truly the people responsible for a majority of the care.
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